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Get VA Form 216-A 2019

gov EXTERNAL REVIEW REQUEST FORM This External Review Request Form must be filed with the Virginia Bureau of Insurance within 120 DAYS after receipt from your health carrier of a denial of payment on a claim or request for coverage of a health care service or treatment. Name of Applicant: Applicant is: (check one) Covered person/Patient Provider Authorized Representative (NOTE: Form 216-B must be completed if the applicant is not the covered person.) Covered Person Information: N.

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